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WESTMINSTER HOMES OF THE LEHIGH VALLEY

MOM & ME SOBER LIVING

First name*

Last name*

Birthday*

Month

Day

Year

Phone*

Email*

Address*

Do you have a sponsor?*

Do you have a home group?*

Do you have a CRS worker?*

Will you commit to all recovery/parenting support program?*

Do you have a job?*

Are you looking for work?*

What is your primary drug of choice?*

How long have you been fighting your addiction?*

What do you hope to receive from this program?*

Do you have any physical disabilities?*

Do you have a health mental diagnosis?*

If YES, what are the mental health disorder you are struggling with*

Depression

Anxiety

Bipolar

PTSD

Schizophrenia

Others

Are you presently on medication?*

If YES, what type of meds and for what purpose? *

What's the age range of your child?*

Pregnant - 3 yrs old

4 - 7 yrs old

8 - 12 yrs old

Other

Are you HIV positive*

Do you have Hepathis C*

Have you been tested for TB*

Are you a registered sex offender*

Do you have or ever had DCFS involvement?*

Who should we contact in case of an emergency? List 3 contact:

Emergency Contact Full Name*

Phone*

Emergency Contact Full Name*

Phone*

Emergency Contact Full Name*

Phone*

What is your Primary Care Doctor's Information?

Primary Care Doctor Full Name*

Phone*

What is your child pediatrician information?

Pediatrician Full Name*

Phone*

Are you involved with another program/agency? If yes, please name the program and how they are helping you*

Please list 3 reasons we should accept you in this program: *

WESTMINSTER HOME OF THE LEHIGH VALLEY

info@whlv.org

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